A client has a herniated lumbar disk at L5. The nurse knows that which of the following symptoms needs to be immediately reported to the RN or physician?
Bowel or bladder incontinence
Lower back pain
Muscle spasms
Pain radiating down one leg
The Correct Answer is A
A. Bowel or bladder incontinence is a medical emergency and should be immediately reported. This symptom can indicate cauda equina syndrome, a condition caused by compression of the spinal nerves at the lower end of the spinal cord. This requires urgent surgical intervention to prevent permanent nerve damage.
B. Lower back pain is a common symptom of a herniated lumbar disk, but it is not an immediate emergency unless accompanied by other severe symptoms.
C. Muscle spasms are also common with a herniated disk and, while uncomfortable, are not immediately life-threatening.
D. Pain radiating down one leg (sciatica) is a typical symptom of a herniated lumbar disk and is often managed conservatively, unless it is severe or accompanied by other neurological deficits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A thrombotic stroke is typically caused by a blood clot that forms in an artery supplying blood to the brain, usually due to atherosclerosis. While it is a possible cause of stroke, it is not the most likely in this patient with atrial fibrillation.
B. A cerebral aneurysm involves a weakness in the blood vessel wall that can lead to rupture and bleeding, causing a hemorrhagic stroke, but this is not the most common type of stroke in patients with atrial fibrillation.
C. Embolic stroke occurs when a clot or other debris (such as a thrombus) breaks off from a distant part of the body (like the heart in atrial fibrillation) and travels to the brain, blocking a cerebral artery. This is the most common type of stroke in patients with atrial fibrillation due to the formation of clots in the left atrium that can embolize to the brain.
D. Hemorrhagic stroke is caused by the rupture of a blood vessel in the brain, leading to bleeding. It is not the most common type of stroke in patients with atrial fibrillation, though it can occur if there is coagulopathy or anticoagulant therapy.
Correct Answer is B
Explanation
A. Shallow, even respirations may be a normal finding or indicate respiratory distress, but it is not a specific sign of increased ICP. It should still be monitored, but it is not the most concerning finding in this scenario.
B. Narrowing pulse pressure, which is the difference between systolic and diastolic blood pressure, is a sign of increased intracranial pressure (ICP). As ICP rises, the body compensates by increasing systolic blood pressure and decreasing diastolic pressure, leading to a narrowing pulse pressure. This is a critical sign that should be reported immediately to the RN.
C. Increased systolic blood pressure is a compensatory mechanism to maintain cerebral perfusion when ICP increases. While it is concerning, it is not as immediately alarming as narrowing pulse pressure, which is a more direct indicator of increased ICP.
D. A pulse of 98 is within normal limits for most adults and does not indicate any immediate concern regarding increased ICP. It should be monitored, but it does not require urgent reporting to the RN.
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